What is the treatment for exercise-induced migraine?

Treatment for Exercise-Induced Migraine

For exercise-induced migraine, prioritize prevention through proper warm-up, hydration, and gradual exercise intensity, and when pharmacologic treatment is needed, use NSAIDs (ibuprofen 400-800 mg or naproxen 500-825 mg) taken 30-60 minutes before exercise as first-line therapy, escalating to triptans for breakthrough attacks. 1, 2

Prevention Strategies (First-Line Approach)

Non-pharmacologic measures are the cornerstone of managing exercise-induced migraine and should be implemented before considering medication:

• Adequate warm-up period before exercise is essential, as gradual increases in heart rate and blood flow may prevent the acute vascular changes that trigger migraine 1, 2
• Maintain proper hydration during activity, as dehydration is a known migraine trigger that becomes more relevant during physical exertion 1, 2
• Ensure adequate nutrition before exercise, avoiding prolonged fasting which can lower the migraine threshold 1, 2
• Optimize sleep hygiene, as sleep deprivation combined with exercise significantly increases migraine risk 2
• Minimize environmental risks such as exercising in extreme heat, high altitude, or poor air quality 2

Acute Pharmacologic Treatment

When prevention fails and exercise triggers a migraine attack, follow the standard stepped-care approach:

First-Line: NSAIDs

• Start with ibuprofen 400-800 mg or naproxen sodium 500-825 mg taken 30-60 minutes before exercise if attacks are predictable 3, 4
• For unpredictable exercise-induced attacks, treat immediately at onset with the same NSAID doses 3
• Critical limitation: Restrict NSAID use to no more than 2 days per week to prevent medication-overuse headache 3, 4

Second-Line: Triptans

• If NSAIDs fail after 2-3 exercise sessions, escalate to triptans (sumatriptan 50-100 mg, rizatriptan, or zolmitriptan) 3, 4
• Triptans work best when taken early in the attack while pain is still mild 3
• Sumatriptan reaches peak concentration in approximately 2 hours orally, with 15% bioavailability 5
• Limit triptan use to ≤10 days per month to avoid medication-overuse headache 3

Third-Line: Newer Agents

• For patients who fail triptans or have cardiovascular contraindications, consider gepants (rimegepant, ubrogepant, zavegepant) or lasmiditan 3, 6

Prophylactic Treatment

If exercise-induced migraines occur more than twice weekly despite preventive measures, initiate prophylactic medication:

First-Line Prophylaxis

• Beta-blockers (propranolol 80-240 mg/day, metoprolol, or atenolol) are first-line, with the added benefit of potentially improving exercise tolerance 3, 7
• Propranolol is FDA-approved for migraine prophylaxis but not for treating acute attacks 7
• Topiramate or candesartan are alternatives if beta-blockers are contraindicated 3

Exercise as Prophylaxis

• Regular moderate-vigorous aerobic exercise at least 3 times per week reduces migraine frequency by approximately 1.5 days per month 8
• The benefit is significantly stronger (5.1 fewer headache days per month) when combined with prophylactic medication 8
• This creates a paradox: exercise can both trigger and prevent migraines, likely due to altered migraine thresholds with regular conditioning 9, 10

Critical Mechanism Considerations

Understanding why exercise triggers migraine helps guide treatment:

• Acute exercise may trigger attacks through CGRP release, lactate metabolism changes, or hypocretin alterations 9
• Regular exercise prevents migraines through increased beta-endorphin, endocannabinoid, and BDNF levels 9, 10
• The key is gradual conditioning - patients with low baseline fitness and high motivation benefit most from exercise therapy 10

Important Pitfalls to Avoid

• Do not allow patients to increase acute medication frequency in response to exercise-induced attacks; instead, transition to prophylactic therapy 3, 4
• Avoid opioids or butalbital-containing compounds, as these lead to medication-overuse headache and dependency 3, 4
• Do not recommend abrupt high-intensity exercise in deconditioned migraine patients, as this increases attack risk 2, 10
• Monitor for cardiovascular contraindications before prescribing triptans, particularly in athletes with undiagnosed hypertension or coronary disease 3, 5

Adjunctive Therapy

• Add metoclopramide 10 mg or prochlorperazine 25 mg if nausea is prominent, taken 20-30 minutes before the NSAID for synergistic analgesia 4
• Consider isometric neck exercises if cervical pain accompanies the migraine 10